Provider Demographics
NPI:1598804528
Name:GALLEGOS, JUAN (MD)
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:
Last Name:GALLEGOS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5904 HOLLY AVE NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87113-2472
Mailing Address - Country:US
Mailing Address - Phone:505-899-3933
Mailing Address - Fax:505-298-2985
Practice Address - Street 1:5904 HOLLY AVE NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87113-2472
Practice Address - Country:US
Practice Address - Phone:505-899-3933
Practice Address - Fax:505-298-2985
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2008-0161208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics